Nokea
The nurse is reviewing new orders for a client with chronic kidney disease. The nurse should clarify the order for
- A. dietary sodium restriction
- B. magnesium hydroxide
- C. fluid restriction
- D. furosemide
Correct Answer: B
Rationale: Magnesium hydroxide risks toxicity in CKD due to impaired excretion. Sodium restriction , fluid restriction , and furosemide are appropriate.
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After the shift report in a labor and delivery unit which of these clients would the nurse check first?
- A. A middle aged woman with asthma and Type 1 diabetes mellitus has a BP of 150/94
- B. A middle aged woman with a history of two prior vaginal term births is 2 cm dilated
- C. A young woman who is a grand multipara has cervical dilation of 4 cm and is 50% effaced
- D. An adolescent who is 18 weeks pregnant has a report of no fetal heart tones and coughing up frothy sputum
Correct Answer: D
Rationale: This client has an actual complication. The others present with findings of potential complications. The adolescent’s symptoms suggest a serious condition, possibly pulmonary edema or fetal demise, requiring immediate assessment.
A 3-month-old infant is treated in the emergency department for a spiral femur fracture. The parent reports that the infant sustained the injury after rolling off the bed. What is the priority nursing action?
- A. Document a description of the injury
- B. Question the parent about where the infant sleeps
- C. Report the injury per facility protocol
- D. Separate the parent from the infant
Correct Answer: C
Rationale: A spiral fracture in a non-mobile infant is inconsistent with rolling off a bed, suggesting abuse. Reporting is the priority to ensure safety. Documentation , questioning , and separation follow.
The hospital nurse administers CPR to an adult male who is found unconscious, has no pulse, and is not breathing. What is the ratio of chest compressions to respirations for one-person rescue?
- A. Fifteen chest compressions to one breath
- B. Fifteen chest compressions to two breaths
- C. Thirty chest compressions to two breaths
- D. Thirty chest compressions to two breaths
Correct Answer: C
Rationale: Current CPR guidelines recommend 30 chest compressions to 2 breaths for one-person adult resuscitation, optimizing circulation and oxygenation.
A client is receiving Vincristine (Marqibo). The client should be taught that the medication can:
- A. Cause diarrhea
- B. Change the color of her urine
- C. Cause mental confusion
- D. Cause changes in taste
Correct Answer: C
Rationale: Vincristine can cause neurotoxicity, including mental confusion. Diarrhea, urine color changes, and taste alterations are less common.
During the interview of a prospective employee who just completed the agency orientation, which approach would be the best for the nurse manager to use to assess competence?
- A. What degree of supervision for basic care do you think you need?
- B. Let's review your skills check-list for type and level of skill
- C. Are you comfortable working independently?
- D. What client care tasks or assignments do you prefer?
Correct Answer: B
Rationale: The nurse needs to know that the employee has competence in certain tasks. One way to do this is to do mutual review of documented skills.